I S S N 183 0 - 7957

2012
ISSUE
SELECTED
PRISONS AND DRUGS IN EUROPE:
THE PROBLEM AND RESPONSES
 2012
ISSUE
SELECTED
PRISONS AND DRUGS IN EUROPE:
THE PROBLEM AND RESPONSES
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Cont ent s

Introductory note and acknowledgements 5

Introduction 7

The context: prisoners in Europe 8

Drug use and its consequences among the prison population 9

Drug use among the prison population 9

Health of drug-using prisoners 13

Mortality among prisoners using drugs 15

Responding to drug-related healthcare needs in prison 16

The European context 16

Responsibility for prison health in the European countries 17

Drug-related prison health policies 18

Provision of drug-related health services in prison 19

Release preparation and throughcare 26

Conclusions 27

References 29

3
Introductory note and acknowledgements

In-depth reviews of topical interest are published as Selected issues each year. These reports are based on information
provided to the EMCDDA by the EU Member States and candidate countries and Norway as part of the national reporting
process.

The most recent Selected issues are:

• Pregnancy, childcare and the family: key issues for Europe’s response to drugs;
• Mortality related to drug use in Europe: public health implications;
• Guidelines for the treatment of drug dependence: a European perspective;
• Cost and financing of drug treatment services in Europe: an exploratory study;
• Treatment and care for older drug users;
• Problem amphetamine and methamphetamine use in Europe;
• Trends in injecting drug use in Europe.

All Selected issues (in English) and summaries (in up to 23 languages) are available on the EMCDDA website:
http://www.emcdda.europa.eu/publications/selected-issues

Links to online sources referred to in this publication are available in the PDF version, available at:
http://www.emcdda.europa.eu/publications/selected-issues/prisons

The EMCDDA would like to thank the following for their help in producing this Selected issue:
• the heads of Reitox national focal points, their staff and the national experts on drug-related deaths;
• the services within each Member State that collected the raw data;
• the members of the Management Board and the Scientific Committee of the EMCDDA;
• the Publications Office of the European Union.

Reitox national focal points

Reitox is the European information network on drugs and drug addiction. The network is composed of national focal points in the EU
Member States, Norway and the candidate countries and at the European Commission. Under the responsibility of their
governments, the focal points are the national authorities providing drug information to the EMCDDA.

The contact details of the national focal points may be found at:
http://www.emcdda.europa.eu/about/partners/reitox-network

5
Introduction
Over the last decade, Europe has seen an increase in the
size of its prison population. As of 1 September 2010, there
were an estimated 635 000 inmates in prison in EU
Member States (Aebi and Del Grande, 2012; Walmsley,
2012). Most of those in Europe’s prisons are from poor
communities and vulnerable social groups (WHO Regional
Office for Europe, 2007), with the proportion of inmates
who are immigrants or from minority ethnic backgrounds on
the increase (Ronco et al., 2011). Drug users form a large
part of the overall prison population, with studies showing
that a majority of prisoners have used illicit drugs at some
point in their life and many have chronic and problematic
drug use patterns. Because of the illegality of the drugs
market and high cost of drug use, which is often funded by
criminal activity, the more problematic forms of drug use are
accompanied by an increased risk of imprisonment.
Although some prisoners do stop or reduce their use of
drugs on prison entry, others initiate drug use or engage in
more damaging behaviours when they are incarcerated
(Lukasiewicz et al., 2007). In addition to high levels of drug
Sources of information on drug use
and health responses in prisons
This Selected issue is based primarily on data provided by the
Reitox network of national focal points, through either yearly
routine reporting or a special data collection (1). The data
available to the EMCDDA include both qualitative information
on drug use and responses in prisons and quantitative data on
prevalence and patterns of drug use among prisoners. In the
absence of a common methodology for monitoring drug use in
prison, the methods used across Europe vary, which limits the
comparability of the data. The drug use statistics presented
here are based mainly on studies carried out since 2006;
however, owing to the scarcity of data, studies from as early as
2000 have been included where more recent data are
unavailable. Data from other EMCDDA sources are also used,
among them data from the treatment demand indicator, which
is applied in some countries in prison, and from the drug-
related infectious diseases indicator. Data on drug use in prison
problems, prisoners also experience poorer health than the
general population, with higher prevalence of blood-borne
infections, such as human immunodeficiency virus (HIV) and
hepatitis C virus (HCV), as well as mental illness. Reported
rates of self-harm and suicide among prisoners are
particularly high compared with the general population of
the same age. In addition, overcrowding and poor hygienic
conditions may further aggravate the stress, social and
health problems experienced by prisoners.
For opioid users, the risk of dying from drug overdose
greatly increases in the period after release from prison
— due to high rates of relapse and lower opioid tolerance
(Farrell and Marsden, 2008). This is a critical time for
action, when ensuring continuity of care and targeted
interventions can both support recovery and save lives. The
services offered to prisoners, however, have historically
compared poorly with those provided in the community
(Stöver and Weilandt, 2007). In general, services provided
for prisoners have tended to mirror those provided in the
community, but with a considerable time lag. Nevertheless,
are presented in the 2012 Statistical bulletin. Additional
information was obtained from the international scientific
literature.
A special data collection on health-related interventions for
drug users in prison was conducted in 2011. This exercise
collected information on healthcare priorities and levels of
availability of selected measures through an expert survey
among the 30 national focal points using a structured
questionnaire. The respondents also provided a detailed report
on the responses for drug-related health problems among
prisoners in their country.
Data on prison populations in Europe were obtained from the
Council of Europe Annual penal statistics 2010 SPACE I by
Marcelo Aebi and Natalia Del Grande. Data on prison
numbers for other countries were obtained from the
International Centre for Prison Studies’ World Prison Brief.
(1) The 2010 Reitox national reports from 27 EU Member States, Croatia,
Turkey and Norway are available on the EMCDDA website.
7
 EMCDDA 2012 Selected issue

when appropriate drug services are in place, periods of
incarceration may provide an opportunity for some to
reduce their drug use and engage with treatment, and, in
recent years, many European countries have increased the
provision of services for drug users in prison, particularly
substitution treatment.
Recent years have also seen an increasing
acknowledgement from international and European
institutions of the importance of treating prison health as an
inseparable component of public health. The Council
Recommendation of 18 June 2003 and the 2009–12 EU
action plan on drugs have both called for the development
and implementation of prevention, harm reduction and
treatment services in prison that are equivalent to services
outside prison (1).
Between 2001 and 2010, the prison population of the 27
EU Member States increased from 582 000 to 635 000.
Over that period, 18 of the 27 EU Member States and
Norway reported increasing numbers of prisoners, a trend
observed in most countries worldwide. The current EU prison
population represents an average of 135 prisoners per
100 000 population, with national figures ranging from
60–70 per 100 000 population in Denmark, the
Netherlands, Slovenia, Sweden and Norway to more than
200 per 100 000 in the Czech Republic, Estonia, Latvia,
Lithuania and Poland (Figure 1).
Figure 1: Prisoners per 100 000 population in EU Member States,
candidate countries Croatia and Turkey and Norway in
2010

This Selected issue approaches the important topic of

prisons and drugs in Europe from two perspectives. The first Less than 100
section aims to provide an insight into patterns and levels of 100 to less than 150
150 to less than 200
drug use among the European prison population, the health 200 to less than 250
profile of prisoners and risk behaviours while incarcerated. 250 and over

The second section examines Europe’s prison health policies

and models of delivery of drug-related healthcare to
detainees, including the provision of prevention, treatment
and harm reduction services. The report concludes with
reflections on ways forward.

The context: prisoners in Europe

In this Selected issue, the term ‘prisoner’ is used in a broad
sense to mean anyone who is held in custody. This definition
includes a range of legal statuses, from detainees who have
not yet been tried to prisoners who are serving custodial
sentences. Source: Council of Europe annual penal statistics: SPACE I — 2010.

(1) Council Recommendation of 18 June 2003 on the prevention and reduction of health-related harm associated with drug dependence OJ L 165 13.7.2003,
p. 31 and EU drugs action plan for 2009–12 OJ C 326 20.12.2008, p. 7.

8
Drug use and its consequences among the prison population
Drug use among the prison population
Drug use, including problem drug use (2), is relatively
common among the prison population. In the European
Union, it has been estimated that about half of the prison
population have used illicit drugs at some time in their lives
(Zurhold et al., 2005). A systematic review of international
studies — with a predominance of studies conducted in the
United States — found that 10–48 % of men and 30–60 %
of women were dependent on or used illicit drugs in the
month before entering prison (Fazel et al., 2006).
Prisoners will have different experiences with drugs and
crime. In Europe, offences related to the use, possession or
supply of illicit drugs are the main reason for incarceration
of between 10 % and 25 % of all sentenced prisoners (Aebi
and Del Grande, 2011). Many, but not all, of these prisoners
will have both experience of and problems with illicit drugs.
Of those prisoners with a history of problematic drug use,
some will have been imprisoned for a drug law offence,
some for a crime committed to support their drug use (e.g.
burglary, shoplifting) and some for offences unrelated to
drugs.
Available data provide some insight into prisoners’ drug use
before prison entry and their use of drugs during their
period of imprisonment.
Experience of drug use among prisoners
Experience of illicit drugs is much more common among
prisoners than among the general population. Among the
17 European countries that have reported data on drug use
(2) The EMCDDA defines problem drug use as ‘injecting drug use or long-duration/regular use of opioids, cocaine and/or amphetamines’. See the problem
drug use indicator on the EMCDDA website for more information.
among prisoners, the proportion of prisoners who have ever
used any illicit drug before imprisonment ranges from 16 %
in Romania to 79 % in England and Wales and the
Netherlands, with nine countries reporting levels of use
higher than 50 % (Figure 2). The variation between countries
broadly reflects national levels of drug use, but may also
partly reflect differences in data collection methods and
practices.
Cannabis is the illicit drug with the highest reported level of
lifetime prevalence among prisoners, with between 12 %
and 70 % having tried it at some time in their lives. This
reflects drug use experience in the general population,
although the levels there are lower (1.6 % to 33 % among
15- to 64-year-olds). Levels of use of cocaine, Europe’s
second most commonly reported illicit drug, both inside and
outside prison, are also much higher among prisoners
(lifetime prevalence of 6–53 %) than among the general
population (0.3–10 %). Experience of amphetamines among
prisoners ranges from 1 % to 45 %, whereas among the
general population the range is from almost zero to 12 %.
Data on lifetime misuse of other substances (such as volatile
substances, hypnotics and sedatives) are limited, and
prevalence levels, among both prisoners and the general
population, are usually low (EMCDDA, 2012).
Prisoners differ greatly from the general population in their
reported experience of heroin. Whereas less than 1 % of the
general population have ever used heroin, lifetime
prevalence levels among European prisoners are much
higher, with eight of the 13 countries that were able to
provide information on heroin use reporting levels between
15 % and 39 %.
9
 EMCDDA 2012 Selected issue

Figure 2: Lifetime prevalence (%) of illicit drug use among prisoners in European countries

Any illicit drug Cannabis Cocaine Amphetamines Heroin

80 Netherlands 80 80 80 80
United
Kingdom (1)

70 70 70 70 70
United
Kingdom
Latvia
Spain
Belgium
60 Finland 60 Latvia 60 60 60
Hungary
Italy
Belgium
Portugal Spain
50 Czech 50 50 50 50
Republic Portugal
Hungary United
% Lithuania Kingdom Hungary
Poland Poland Latvia
40 Greece 40 40 Italy 40
40 Spain
Belgium (2) Poland
Czech United
Bulgaria Republic United
Portugal Kingdom Kingdom
Italy Italy
Czech
30 30 30 30 Republic 30 Portugal
Slovenia Finland Belgium
Bulgaria
Spain Latvia
Hungary Bulgaria
20 20 20 Poland 20 20
Bulgaria
Latvia Hungary
Romania Bulgaria
Romania Portugal
Czech Czech
Croatia Republic Republic
10 10 10 10 10
Croatia Poland
Romania Croatia Romania
Italy Croatia
Finland (3)
0 0 0 0 Romania 0

(1) Any of amphetamines, cannabis, crack, cocaine or heroin.

(2) Includes crack cocaine.
(3) Opioids.
NB: Data refer to lifetime prevalence of use prior to imprisonment, with the exception of data for Belgium and Bulgaria, which refer to lifetime prevalence
inside and outside prison. The prisoner sample in Finland was made up of convicts presenting for voluntary HIV testing; in the United Kingdom, the
sample consisted of adults receiving sentences of between 1 month and 4 years. The studies were carried out in 2000 (Greece), 2001 (Finland),
2003 (Italy, Lithuania, Netherlands), 2005/6 (United Kingdom), 2006 (Spain, Romania), 2007 (Poland, Portugal), 2008 (Slovenia), 2009 (Hungary)
and 2010 (Belgium, Bulgaria, Czech Republic, Latvia, Croatia).
For further information see Table DUP-1 in the 2012 Statistical bulletin.
Sources: Reitox national focal points.

Drug use within prison
Imprisonment forces some drug users to stop using drugs,
and some will see this as an opportunity to improve their
lives. For others, however, prison may be a setting for
initiation into drug use or for switching from one drug to
another, often due to lack of availability of the preferred
drug inside prison (Fazel et al., 2006; Stöver and Weilandt,
2007) and other possible reasons (e.g. use of substances for
which avoiding control measures is easier). Sometimes, this
change leads to more harmful patterns of drug use (Niveau
and Ritter, 2008). For example, a Belgian study carried out
in 2008 found that more than one-third of drug-using
prisoners had started to use an additional drug during
detention, one that they were not using before entering
prison, with heroin being the drug most frequently
mentioned (Todts et al., 2008).
Studies carried out in 15 European countries since 2000
estimated that between 2 % and 56 % of prisoners have
ever used any type of drug while incarcerated, with nine
countries reporting levels in the range 20–40 % (3). The

(3)  See Table DUP-1 in the 2012 Statistical bulletin.

10

Imprisonment and drug use:
the international picture
At an estimated 135 prisoners per 100 000 population, the
level of incarceration in Europe is similar to that in Australia
(134 per 100 000) and higher than that in Canada (117
per 100 000). Considerably higher levels of imprisonment
are reported in the United States (743 per 100 000 in
2009) and Russia (590 per 100 000) (Aebi and Del
Grande, 2011; Walmsley, 2012).
Outside Europe, data on drug use among prisoners mainly
come from the United States, Australia and Canada.
Despite the methodological differences in monitoring drug
use in prison between different countries and world
regions, data from all three countries show that the
prevalence of drug use among prisoners prior to
incarceration is substantially above the level in the general
population. Comparing estimates of the more problematic
forms of drug use between countries is hampered by the
lack of an agreed international definition of the condition.
The available European data indicate that one-third of
prisoners show problematic drug-use patterns. In Canada,
the percentage of prisoners diagnosed as having a
substance abuse problem (70 %) is the nearest comparable
measure, although this includes alcohol problems (CCSA,
2012). In the United States, 65% of prisoners reportedly
meet the criteria for substance use disorder under the
Diagnostic and Statistical Manual of Mental Disorders, 4th
edition (CASA, 2010).
In Australia, two-thirds of all prison entrants reported using
illicit drugs in the 12 months prior to prison entry. The most
common illicit substances used by prisoners before
incarceration were, in the following order: cannabis (51 %),
methamphetamine (30 %), analgesics (16 %), tranquillisers
(12 %), heroin (10 %) and ecstasy (10 %) (AIHW, 2011).
Also in Australia, a recent study found that 36 % of
prisoners reported the illicit use of pharmaceutical drugs
such as buprenorphine, morphine, benzodiazepines or
dexamphetamine at least once in the past 12 months (Ng
and Macgregor, 2012).
There are also reports of high levels of experience of
injecting drug use among prison populations outside
Europe, with 34 % of Canadian drug offenders in prison
and 55 % of Australian prison entrants reporting ever
having injected a drug. Injecting while in prison is reported
by 11 % of Canadian inmates.
(4)  See Table DUP-3 in the 2012 Statistical bulletin.
Prisons and drugs in Europe: the problem and responses
drug most frequently used by prisoners is cannabis, followed
by cocaine and heroin. Estimates of heroin use while in
prison ranged from 1 % to 21 % of prisoners (4). The wide
variation in prevalence levels between countries may reflect
methodological differences in data collection and reporting.
Factors such as price and availability will influence the
substances used within prison, but studies suggest a
tendency towards the use of depressant-type drugs such as
heroin, hypnotics and sedatives or drugs with depressant
effects such as cannabis. Stimulant drugs may be less
popular, as the effects can be more difficult to manage, for
both prisoners and prison staff, within the confined prison
setting (Bullock, 2003).
Drug injecting and other health risk
behaviours among prisoners
The close associations between injecting drug use and
serious health risks, including blood-borne infections and
overdose, have led to research into drug use patterns
among prison populations focusing largely on drug
injecting.
Lifetime prevalence of injecting drug use is substantially
higher among prisoners than among the general population.
European countries report that between 2 % and 38 % of
prisoners have ever injected heroin or other drugs prior to
imprisonment. The most robust overall figure for drug
injection among the European general population refers to
those currently injecting, who are estimated to represent
about 0.3 % of the adult population of the European Union.
In studies carried out in Europe since 2000, estimates of the
prevalence of ever injecting illicit drugs while in prison
range from 2 % to 31 % (Table 1). Data, however, are
available for only a few countries, and differences in
methodology mean that caution is required when comparing
countries. The findings of qualitative studies suggest that in
prison settings the likelihood of injecting in order to
maximise the effect of the substance could increase, owing
to the scarcity of drugs (EMCDDA, 2010b; Pena-Orellana et
al., 2011). In addition, the scarcity of sterile equipment may
lead to prisoners sharing syringes and other injecting
paraphernalia, which increases the risk of infections.
11
 EMCDDA 2012 Selected issue

Table 1: Lifetime prevalence of drug injecting

before and during imprisonment, Prison experience among problem drug users
in selected European countries
Studies among problem drug users show that many have
Prevalence of drug injecting (%) Year of spent time in prison, with between one-third and three-
study quarters of different samples of users of opioids, cocaine
Prior to During
and amphetamines and injecting drug users having ever
imprisonment imprisonment
been in prison. Among problem drug users, evidence from
Belgium 15.2  2.3 2010 a Norwegian study suggests that males are more likely
Bulgaria (1)  7.3  2.7 2009/06 (2) than females to have been imprisoned at some time, and
that males serve longer sentences (Ravndal and
Czech Republic 22.1  8.4 2010
Amundsen, 2010).
Germany 31.0 22.2 2007
Problem drug use and drug dependence will increase the
Spain 25.7  3.1 2006
risk of imprisonment, due to the illegality of the drugs
France  7.0  — 2003 market and high cost of drug use, which is often funded by
criminal activity. In addition, studies suggest that
Italy 30.4  — 2001–02
incarceration has an additional negative impact on these
Latvia (1) 21.1  8.5 2010 already vulnerable populations. Imprisonment is, for
Luxembourg  — 31.0 2005 example, associated with higher rates of heroin or cocaine
use, both in prison and outside prison (Gaffney et al.,
Hungary 10.4  0.7 2008
2008), increased benzodiazepine use in injecting drug
Poland ( )3
 5.9  3.3 2001 users (McIlwraith et al., 2012), and earlier relapse after
inpatient treatment (Smyth et al., 2010).
Portugal 12.6  1.9 2007

Romania  6.0  — 2006 In light of the large overlap that exists between prison and
problem drug use populations, prison samples (and
United Kingdom
(England) (4) 37.8  6.9 2004–05
criminal justice-involved samples, in general) are an
important source of data for understanding the
United Kingdom characteristics and estimating the size of populations of
(England and Wales)  —  1.0 2001–02
problem drug users, as they offer an opportunity to reach
United Kingdom problem drug users who might never, or only much later,
(Scotland)  —  7.5 2009
contact drug treatment services. Comparing their
Croatia  2.5  — 2010 characteristics with treated clients gives a better
understanding of treatment needs that are as yet unmet by
(1) Heroin. existing services.
(2) Data for injecting prior to imprisonment refer to 2009, data for
injecting during imprisonment are from 2006.
(3) Adult males.
(4) Female prisoners.
Sources: Reitox national focal points. inmates’ vulnerability to HIV and other infections may be
indirectly increased by factors related to prison
infrastructure and management, including overcrowding,
Additional risk factors for blood-borne infections include violence and inadequate medical and social services
consensual and non-consensual unprotected sexual activity, (Jurgens et al., 2011; Rotily et al., 2001).
including sexual assault and rape, which are reported to
occur frequently in prison. In a large study conducted in Social and demographic characteristics
Luxembourg in 1998, 90 % of the prisoners who reported of drug treatment clients in prison
having had sex in prison did not use condoms (Schlink,
1999); in a recent study, the corresponding proportion was Information on the social characteristics of prisoners with
40 % (Origer and Removille, 2007). A number of other drug problems is scarce, both in the scientific literature and
practices that are relatively frequent in prison are from routine data; it mainly comes from qualitative studies
associated with increased risk of spread of infectious (Vandam, 2009). Data on those entering drug treatment
disease, including the sharing or re-use of tattooing and while in prison may provide a source of information on the
body-piercing equipment, sharing of razors, blood- social and demographic characteristics of drug users in
sharing/‘brotherhood’ rituals and the re-use or inadequate prison settings. However, as only a small number of
sterilisation of medical or dental instruments. In addition, countries collect these data, and coverage may be limited, it

12

must be borne in mind that this dataset can describe only a
subset of drug users receiving treatment in prison settings.
Data on drug users entering treatment in prison show that,
prior to incarceration, they have experienced generally
poor social conditions, with many of them having a low
level of educational attainment, while unemployment and
living in unstable accommodation are also common.
Furthermore, violence, abuse and poverty feature in the
history of many prisoners who have used or are using drugs
(Ronco et al., 2011).
Eight countries were able to provide information on
prisoners entering drug treatment in 2010 (Germany,
Ireland, France, Luxembourg, Hungary, Romania, Slovakia
and Sweden, with a total of 5 146 prisoners). In these
countries, the social profile of drug clients entering
treatment in prison, while being generally similar to that of
those entering treatment in the community, had some
distinct characteristics. Men accounted for a greater share
of those entering treatment in prison (around 90 %) than in
community settings (80 %). And, while the average age of
treatment clients was similar in the two settings (29 years in
prison and 30 years in the community), prisoners reported
an earlier age of first use of the primary drug for which
they were receiving treatment (18 years compared with 21
years among non-prisoners). Overall, heroin use was
frequently the main reason for entering treatment in prison,
although other primary drugs were reported by high
proportions of prisoners entering treatment in several
countries.
Health of drug-using prisoners
The health needs of prisoners are diverse and complex.
Prisoners suffer from high levels of physical and psychiatric
disorders, ranging from infectious diseases (HIV/AIDS,
hepatitis B and C, tuberculosis) to psychiatric co-morbidity
(antisocial and borderline personality disorder, depression,
post-traumatic stress disorder, psychosis and alcohol
dependence) (ECDC, 2010).
Prison conditions may also have a detrimental impact on
prisoners’ health. Overcrowding, in particular, is linked with
increased stress and tension (Rouillon et al., 2007). In 15 out
of 30 European countries (27 EU Member States, Croatia,
Turkey and Norway) the occupancy rate in prison is over
100 %, ranging from 102 % in Ireland to 153 % in Italy,
according to the latest statistics from the Council of Europe
(Aebi and Del Grande, 2012). In addition, the poor and
unsanitary detention conditions in some prisons are likely to
impact on the health of prisoners (WHO Regional Office for
Europe, 2007).
Prisons and drugs in Europe: the problem and responses
Differences in morbidity between the prison population and
the general population are shown by several studies, with
prisoners more often presenting a problematic mental health
profile (Fazel and Danesh, 2002). Compared with the
general population, prison inmates experience poorer
physical and mental health and social well-being, including
both acute and long-standing physical and mental illness and
disability, sexual health problems, suicide, self-harm, physical,
psychological and sexual violence, lower life expectancy and
breakdowns in family and other relationships, drug, alcohol
and tobacco dependency (Barry, 2010).
According to recent European and international studies
more than one-third of prisoners had an alcohol problem
Health needs of female drug users in prison
On a given day more than 30 000 women are imprisoned
in Europe, where they account for about 5 % of the prison
population. Between 2000 and 2010, the number of
women in prison grew by 27 %, and women’s share of the
prison population also rose. Part of the increase may be
due to women drug couriers, many of whom have been
coerced into carrying drugs. In the United Kingdom, for
example, female foreign nationals represented 19 % of the
female prison population, with 80 % of them convicted of
drugs offences (Corston Report, 2007). These women form
a group with special needs.
Women prisoners are more likely than their male
counterparts to have been incarcerated for drug offences
(Borrill et al., 2003) and to have serious drug-related health
problems (Fazel et al., 2006), including infectious diseases
(UNODC, 2008c). Female prisoners have specific
treatment needs that are interwoven with their drug use
history and drug-related lifestyles: many have experienced
trauma related to physical and sexual abuse and violence
and have to deal with mental health co-morbidities (WHO
Regional Office for Europe, 2009). In addition, the risk of
drug-related death is particularly acute among newly
released women (Farrell and Marsden, 2008).
Responding to the requirements of women is challenging
for prison authorities, because facilities and programmes
are not typically developed to meet the specific
psychological, social and healthcare needs of this small
minority of inmates. Making sure that women have access
to integrated treatment that addresses mental and somatic
co-morbidities as well as drug dependence has been
recommended (WHO Regional Office for Europe, 2009)
alongside the systematic preparation of women prisoners
for release, throughcare to drug treatment in the community
and support to re-establish social support networks and
family relationships (UNODC, 2008b).
13
 EMCDDA 2012 Selected issue
in the last year before entering prison (Lukasiewicz et al.,
2007), and almost 80 % smoked tobacco prior to arrest,
compared with around 20–30 % in the general
population (Hayton and Boyington, 2006; Kauffman et
al., 2011).
Infectious diseases among injecting
drug users in prison
HIV and hepatitis C virus
European data on HIV infection among injecting drug users
in prison, albeit limited, show that the prevalence of
infection varies, and in some countries it can be high
among prisoners who have ever injected. Among the five
countries providing data on HIV infection among injecting
drug users in prisons between 2005 and 2010, HIV
prevalence ranged from zero to 7.7 % in four countries
while Spain reported a prevalence of 39.7 %. Reports from
European countries with a high prevalence of HIV among
injectors outside prison suggest that HIV prevalence is also
high among injectors in prison. As higher proportions of
prisoners inject or have injected drugs, the prevalence of
HIV in prison populations can be much higher than that in
the general population (5).
Data on hepatitis C virus (HCV) antibody prevalence among
injecting drug users in prison between 2005 and 2010 were
reported by five countries, with prevalence ranging from
11.5 % (Hungary) to 90.7 % (Luxembourg).
An analysis of studies undertaken in the community and
reported to the EMCDDA, mostly in drug treatment and
low-threshold services, assessed whether HIV prevalence
differs by prison history of injecting drug users. Data since
2005 from 15 European countries were analysed. HIV
prevalence among injecting drug users who reported ever
having been in prison (5.6 %) was about twice that among
injectors who reported never having been in prison
(2.6 %). A similar pattern was found for HCV infection,
with a prevalence of 63 % among injecting drug users
who reported having ever been in prison and 43 %
among those who reported that they had never been in
prison. The increased risk of HCV infection varied from 1.1
times in Greece to 7 in Sweden and 19 times higher risk in
Cyprus. Overall, the data suggest that, for injecting drug
users in most countries, a history of imprisonment is
associated with a two- to threefold increase in the risk of
HCV infection, while in France, Cyprus and Sweden the
increase is higher.
(5)  See Table INF-1 in the 2012 Statistical bulletin.
14
Tuberculosis
Prisons play a key role in the epidemiology of tuberculosis in
Europe. The disease is more common among marginalised
sections of the population, including those with drug
problems, than in the community at large, and prevalence
rates in European prisons usually far exceed those in the
general population (Aerts et al., 2006). A recent systematic
review indicates that the risk of acquiring tuberculosis is at
least ten times higher in prisons than in the general
population (Baussano et al., 2010). Conditions such as
overcrowding and poor ventilation facilitate the transmission
of tuberculosis among the prison population. Similarly,
through infected visitors, prison staff and released prisoners,
tuberculosis may be transmitted into the community.
Psychiatric co-morbidity
Psychiatric co-morbidity is the co-occurrence of two or more
mental disorders, usually a mental health and substance use
disorder, in the same person. It particularly affects
vulnerable groups, including problem drug users and prison
populations, which are, to a large extent, overlapping.
Studies have estimated that for several types of mental
health disorders, including psychosis, personality disorders,
anxiety and depression, co-morbidity occurs at substantially
higher prevalence rates among prisoners than in the general
population (Fazel and Baillargeon, 2011).
A systematic review of 62 surveys covering about 23 000
prisoners from 12 countries worldwide showed that up to
65 % of prisoners have a mental health disorder, which may
range from personality disorder (42–65 %, mostly antisocial
disorder), to major depression (10–12 %) to psychotic
illnesses (4 %; including schizophrenia, schizophreniform
disorder, maniac episodes and delusional disorder). Those
disorders represent a serious risk factor for suicide, which is
the leading cause of death among those who are
imprisoned (Fazel and Danesh, 2002).
Studies from European countries, including Spain, France
and the United Kingdom, support those results (Birchard,
2001). Particular attention has been drawn to personality
disorders, which are often associated with problem drug use
(Arroyo and Ortega, 2012). In a French study, the most
common problems among prisoners with a diagnosis of
psychiatric co-morbidity were depressive syndromes (40 %),
generalised anxiety (33 %), traumatic neuroses (20 %),
agoraphobia (17 %), schizophrenia (7 %), and paranoia or
chronic hallucinatory psychoses (7 %) (Rouillon et al., 2007).

Mandatory drug testing in prison
The main purpose of mandatory drug testing is to prevent
inmates from consuming drugs inside prisons and to identify
those who require treatment. The information obtained can
also be used to estimate the level of use and the types of
drugs being used in prisons (Stöver et al., 2008).
Mandatory drug testing in prisons was first established in a
number of European countries in the 1990s (MacDonald,
1997), and is now carried out in most EU Member States.
Urinalysis is the prevailing method employed, although
countries report various methods and objectives of drug
testing. Other types of biological samples are analysed,
such as blood and oral fluids, hair follicles and sweat
(Hoffmann, 2009). In addition to random testing, in some
European countries inmates may also be tested upon
prison admission, on suspicion of use, and before they
leave the prison.
There are a number of problems associated with drug
testing in prisons including cost, increased tension among
prisoners, and negative impact on treatment compliance
and effectiveness (Stöver et al., 2008). Studies have also
reported links between testing and increases in harm. Drug
testing is more likely to identify cannabis users, since
metabolites of tetrahydrocannabinol, the main psychoactive
chemical in cannabis, have a longer duration in the body
than those of cocaine and heroin. This could lead would-be
cannabis users to switch to ‘harder’ drugs. However, there
is insufficient evidence to generalise these findings, and
more research is needed to establish the efficacy of
mandatory drug testing in prison (Bird, 2005).
Mortality among prisoners using drugs
Mortality among prisoners in general is high (30.6 per
10 000 per year), according to a study of suicide and
mortality in prisoners, using supranational data from the
Council of Europe Annual Penal Statistics (SPACE) from
1997 to 2008. Suicide is the leading cause of death in
prison and accounts for around one-third of all prison
deaths. In Europe, the risk of suicide among prisoners (10.5
per 10 000 in prison) is estimated to be seven times that of
the general population (EU average of 1.5 per 10 000
population) (Rabe, 2012).
Drug-using prisoners represent a sizeable proportion of the
prison population, and, while the evidence is not conclusive,
it is likely that drug users represent a considerable share of
the suicides in prison. Meta-analysis of studies suggests that,
among other factors, drug problems might be a risk factor
for committing suicide in prison (Fazel et al., 2011; Laishes,
Prisons and drugs in Europe: the problem and responses
1997). And studies show that, in the community, drug users
are more likely than the general population to commit
suicide (Darke and Ross, 2002).
In England, a study on 172 prison suicides in 1999–2000
found that the most common methods of suicide were
hanging and strangulation, using bed clothes and window
bars (92 %), and only 3 % of the victims died of self-
poisoning (overdose). Drug-dependent prisoners who
committed suicide did it early, and were twice as likely as
other prisoners to commit suicide in the first week of
detention. For all inmates, the authors identified the days
following reception into prison as the period when suicide
prevention measures are most needed, and that, in this
respect, drug-dependent prisoners should be identified as a
high-risk population and targeted by prevention measures
(Shaw et al., 2004).
Mortality after prison release
Release from prison is a time associated with increased
mortality from all causes and, in particular, from drug
overdose. This risk does not appear to have decreased in
the last 20 years (WHO Regional Office for Europe, 2010).
During the period following release from prison and return
to the community, prisoners face a range of physical,
practical and psychosocial challenges (Binswanger et al.,
2011). For prisoners with a history of problematic drug use,
this is a time of very high overdose risk, as a result of
reduced tolerance to opioids and frequent relapse into
heroin use. A review of drug-related deaths that occurred
shortly after release from prison in Europe, Australia and
the United States showed that six out of 10 deaths in the
first 12 weeks after release were drug-related (Merrall et
al., 2010). The authors concluded that there is an
increased risk of drug-related death during the first two
weeks after release from prison, and that the risk remains
elevated up to at least the fourth week. A study in England
and Wales also reported that six out of 10 deaths in the
first two weeks after release were drug-related and that the
risk of death was greatly elevated during the first two
weeks following release from prison. During the first week
after release, compared with the general population of the
same age and sex, female prisoners were 69 times more
likely to die of drug-related causes and male prisoners 28
times more likely (Farrell and Marsden, 2008). In addition,
an Irish study of drug users who died after prison release
between 1998 and 2005 showed a considerable risk of
death at the time of release. Among the 105 deaths
identified, 28 % occurred within the first week of release
from prison and a further 18 % in the first month (Lyons et
al., 2010).
15
 Responding to drug-related healthcare needs in prison
The European context
Responding to the drug-related healthcare needs of
prisoners has been identified as a public health priority by
the European Union and Member States. This is evident in
the EU drugs action plan 2009–12, which sets for Member
States the objective of providing drug users in prison with
improved access to healthcare, in order to prevent and
reduce health-related harm associated with drug
dependence. It is also expressed in the Dublin Declaration
on Partnership to fight HIV/AIDS in Europe and Central
Asia, which identifies prisoners as a vulnerable population
and sets time-bound targets for national governments to
provide comprehensive HIV/AIDS services for them
(ECDC, 2010).
A number of recommendations and resolutions that address
the broader topic of prison health have been adopted by
the Council of Europe, through its Council for Penological
Cooperation under the Committee of Ministers (6), including
the European Prison Rules (7). In addition, guidance
translating internationally recommended health standards
into the prison setting and promoting evidence-based
health interventions in prisons has been issued, including
the World Health Organization’s (2007) health in prisons
guide and the United Nations Office on Drugs and Crime’s
(2012) briefing on HIV prevention, treatment and care in
prisons.
To set the context for the care for drug-related problems in
prison, this section first examines the administration of prison
healthcare in European countries, and reviews national
policies. This is followed by an overview of the available
information on drug-related service provision in Europe,
from prison entry to prison release, addressing counselling,
treatment of drug dependence and the prevention of
infectious diseases.
(6)  A compendium of the work of the Council of Europe published in 2007 is available online.
(7)  See the box ‘Prison health standards in Europe: the European Prison Rules’.
16
The rights of prisoners in the European Union
In response to concerns about increasing prison
populations, including overcrowding and rising numbers of
foreign nationals in European prisons, in 2004, the
European Parliament adopted a recommendation on the
rights of prisoners in the European Union (a), which refers to
the EU legal instruments dealing with the protection of
human rights (b), treatment of drug users in prison (c) and
reduction of health-related harm (d), as well as to the
corresponding instruments adopted by the Council of
Europe and the United Nations. The Parliament
recommended the drafting of a binding prisons charter for
Europe as well as the revision of the 1987 European Prison
Rules (e), in order to incorporate a higher degree of
protection. In the context of the adoption in 2008 of an EU
framework decision (f) implying the option of a transfer of a
sentenced prisoner to serve the remainder of the sentence
in another Member State, growing importance is now
being attached to ensuring common minimum prison
standards across the EU Member States and to the
exchange of best practices.
(a) European Parliament recommendation to the Council on the rights of
prisoners in the European Union (2003/2188(INI)) — document P5_
TA(2004)0142 (available online).
(b) The Treaty on European Union and the Charter of Fundamental Rights
of the European Union (available online).
(c) Council Resolution on the treatment of drug abusers in prison,
adopted at the meeting of the Justice and Home Affairs Council on
27–28 February 2003 (available online).
(d) Council Recommendation of 18 June 2003 on the prevention and
reduction of health-related harm associated with drug dependence,
OJ L 165, 3.7.2003, p. 31 (available online).
(e) Recommendation Rec(87)3E of the Committee of Ministers on the
European Prison Rules (available online).
(f) Council Framework Decision 2008/909/JHA of 27 November 2008
on the application of the principle of mutual recognition to judgments
in criminal matters imposing custodial sentences or measures
involving deprivation of liberty for the purpose of their enforcement in
the European Union (available online).

Responsibility for prison health
in European countries
In Europe, the responsibility for the provision of healthcare in
prisons has historically lain with the same ministry that is in
charge of the overall management of prison services —
generally the justice or interior ministries. In practice, this
means that decisions about prison health are taken by the
national prison administrations or specialised executive
agencies such as the Criminal Sanctions Agency in Finland,
the Custodial Institutions Agency in the Netherlands or the
Irish Prison Service. In several countries, namely Belgium,
Germany, Malta, Portugal, Finland and Norway, prison
health policies are dealt with at regional or prison levels.
Seven countries, accounting for 40 % of all prisoners in the
European Union and Norway (8), have transferred or are in
the process of transferring competence for delivering
prisoner healthcare to the same structures that provide
healthcare in the community. An important rationale for this
change has been the need to integrate prison health
structures with those in the community and improve the
continuity of care for prisoners. In some countries, the move
followed recognition of the need to tackle prison health
problems more effectively, and to improve the quality of
care for prisoners through easier access to medical
specialists from public health structures. In some countries,
such as Sweden and the United Kingdom, this move seems
to have been accompanied by increased funding to engage
prisoners in drug treatment programmes.
Among EU Member States, Sweden has the longest
experience of involving the Ministry of Health in prisons,
with a law from the early 1980s (Bill 1982/83:85)
stipulating that general health services should care for
prisoners just as they care for other citizens. However, while
the Ministry of Health funds the medical treatment of
inmates, prison healthcare units are run by the Swedish
Prison and Probation Service under the Ministry of Justice,
which is also in charge of providing cognitive treatment and
educational activities targeting imprisoned drug users.
In Norway, since 1988, municipal health services have been
responsible for the provision of primary healthcare to the
inmates of prisons located in their area. As the Norwegian
prison system consists of many small prisons, this solution
offers practical advantages, including better availability of
healthcare. Steps are currently being taken towards a further
integration of service provision, in particular the
incorporation of specialised drugs care and rehabilitation
competence in prisons.
(8)  Spain, France, Italy, Slovenia, Sweden, United Kingdom and Norway.
Prisons and drugs in Europe: the problem and responses
Prison health standards in Europe:
the European Prison Rules
European and international prison rules (1) promote
equivalence of care between prison and community and
provide guidance on the organisation of imprisonment,
including preparation for release as well as prison
inspection and monitoring. The standards set by these rules
provide a frame of reference for the judgments of the
European Court of Human Rights, and are a benchmark
against which conditions of detention are evaluated in
Member States.
The European Prison Rules include a set of
recommendations on the organisation and provision of
healthcare and on the qualifications and duties of the
medical staff. The principles stipulated in the Prison Rules
apply equally to the provision of healthcare for problems
related to drug use. Under the ‘principle of equivalence’,
prisoners shall have access to the health services available
in the country, without discrimination on the grounds of
their legal situation; the prison health staff shall have
adequate training and be able to identify mental health
problems; and those in need of specialised treatment not
available in prison shall be transferred to external
institutions.
(1) Standard Minimum Rules for the Treatment of Prisoners (SMRTP),
adopted by the First United Nations Congress on the Prevention of
Crime and the Treatment of Offenders, held at Geneva in 1955, and
approved by the Economic and Social Council by its resolutions 663
C (XXIV) of 31 July 1957 and 2076 (LXII) of 13 May 1977 (available
online) and Recommendation Rec(2006)2 of the Committee of
Ministers to Member States on the European Prison Rules (available
online). The European Prison Rules follow the general lines of the
SMRTP, which set out consensual principles and practices in the
treatment of prisoners, covering accommodation, hygiene, food,
exercise and medical services.
In France, since 1994, prison healthcare has been provided
through the public hospital system. Each prison has an
agreement with a public hospital, which is responsible for
the healthcare of the inmates. Addiction treatment costs are
covered by French social security, and contributions for
inmates to the scheme are paid by the Ministry of Justice.
Between 2003 and 2006, responsibility for commissioning
and funding healthcare in public prisons in England and
Wales was transferred from the prison administrations to
public healthcare providers. The change was accompanied
by an increase in funding of 78 % in England and 30 % in
Wales. In Northern Ireland, the South Eastern Health and
17
 EMCDDA 2012 Selected issue
Social Care Trust took charge of prison health in 2008, and,
in Scotland, the transfer to the National Health Service took
place in 2011.
In Spain, the management of all prison healthcare units, the
planning of drug policies, epidemiological surveillance and
the prison health information systems are coordinated under
the secretary general of Spanish prison institutions. Care is
provided using an integrated model with shared funding
from the Ministry of Interior for primary health services and
from the Ministry of Health for external healthcare services
delivered by non-governmental agencies. All prison
healthcare personnel are currently being transferred from
the national Ministry of Interior to the health structures of the
Autonomous Communities.
In Italy, the Ministry of Health has been responsible for
prison health since 2008, and all health units in prisons
operate under its authority. In Slovenia, regional health
centres became responsible for prisoner healthcare in 2009,
when prison health was integrated in the public healthcare
system.
Drug-related prison health policies
Drug-related health issues in prisons have been an important
focus for European policymakers in recent years. Two
reports issued by the European Commission in 2007 (9) and
2008 (Stöver et al., 2008) highlighted the lack of available
services for drug users in prisons and drew attention to the
importance of intervening in this setting. As noted earlier,
improved provision of healthcare for drug users in prison
has been an objective in the 2009–12 action plan on drugs,
and 15 EU Member States, as well as Croatia and Norway,
specifically address drug-related prison health in their
national drug policies.
Furthermore, in 10 EU Member States, drug-related prison
health is covered in a national prison health strategy, in a
strategy dedicated specifically to drug-related prison health,
or in both.
There is evidence of increasing coordination and
cooperation between agencies around prison health
planning and service provision. An example of a recent
multi-stakeholder prison health plan is the French strategy
‘Santé/Prison’ for 2010–14, developed by the Ministry of
Health and Sports in collaboration with the Ministry of
Justice and Liberties and involving the National Institute for
Prevention and Health Education (INPES), the National
(9) COM report on follow-up to Council Recommendation of 18 June 2003 on the prevention and reduction of health-related harm associated with drug
dependence (available online).
18
Institute for Public Health Surveillance (InVS) and the Agency
for Shared Information Systems (ASIP Santé), as well as a
general adviser for health establishments. This national
strategic action plan for improving the health of detainees is
consistent with the objectives of the French national action
plan on drugs and drug addictions (2008–11) and
emphasises the importance of continuity of care after
release from prison, especially through the provision of
housing.
In England, since 2008, an integrated drug treatment system
(IDTS) has been implemented in all adult prisons, with the
aim of improving the coordination of planning and delivery
of all drug treatment interventions, both clinical and
psychosocial. The IDTS aims to improve collaboration
between prisoners and the prison system through an
individual treatment plan, and to ensure continuity with
community treatment at both the start and finish of custody.
Each prison has its own drug and alcohol strategy, and a
review of this is carried out annually. Also in the United
Kingdom, a prison drug treatment strategy review was
carried out, under which an independent expert group
assessed rehabilitation measures for drug users in prison
and on release with regard to their effects on reducing
drug-related crime and rehabilitating offenders, and came
forward with recommendations for an evidence-based
approach to prison drug treatment (Prison Drug Treatment
Strategy Review Group, 2010).
In Portugal, the provision of healthcare, treatment and harm
reduction measures is ensured through the use of
collaboration procedures between the health and justice
ministries.
In the majority of European countries, drug treatment in
prisons is provided by staff employed by the prison
administration. However, it is also common for prison
administrations to collaborate with a range of community-
based providers, public health services or non-governmental
organisations in order to deliver drug treatment services to
those in detention. Collaboration can entail bringing in
personnel from public services to work alongside prison staff
or having external providers ‘reach in’ and work
independently inside prison. In the Netherlands, mixed
teams are the main providers of all types of drug treatment
in prisons, and in the United Kingdom they are the main
providers of opioid substitution treatment. In Greece,
non-governmental organisations are the only provider of
drug treatment in prisons.

Provision of drug-related
health services in prison
As a general principle, prisoners are entitled to the same
level of medical care as persons living in the community,
and prison health services should be able to provide
drug-related treatment and care in conditions comparable to
those enjoyed by patients outside (10). The following sections
describe what drug-related health services are provided to
prisoners on entry into custody, during imprisonment and
upon release.
Prison entry
Medical examination of all those remanded in custody or
entering prison after conviction is a widely accepted
standard of prison healthcare. The aim here is to diagnose
any physical or mental illnesses that might be present and
take the necessary treatment measures, such as ensuring the
continuation of existing medical treatment. Although
information from some countries is incomplete, a general
picture emerges from the available data. The overall health
condition of prisoners is screened by the prison doctor or
nurse immediately at entry or within the first 24 hours and,
in several countries, withdrawal symptoms are assessed and
medication needs are established.
This is followed by a comprehensive medical examination,
which takes place in a specified time, which can vary
depending on the country from ‘within the first working day’
to up to ‘within 20 working days’. This examination typically
involves a thorough medical assessment (11), an evaluation of
the need for specialist care and the testing for blood-borne
viruses and sexually transmitted infections.
Tests for infectious diseases should be offered but should not
be mandatory (EMCDDA, 2010a). Information on specific
screening policies was available from only a few countries.
For example, in Romania, HIV screening requires written
consent; however, if the prisoner tests positive, screening for
sexually transmitted infections will also be performed. In
Estonia, where tuberculosis affects more than 20 per
100 000 inhabitants, and where an increase in tuberculosis
patients carrying multidrug-resistant pathogens was detected
in 2010, a more active tuberculosis screening is
implemented based on the national tuberculosis prevention
strategy (2008–12). During the medical examination on
(10) See also the box on the European Prison Rules, p. 17.
(11) European Prison Rules — Part III: Health — Duties of the medical practitioner — Rule 43.2. Available online.
(12) The Addiction Severity Index (ASI) is an assessment instrument, designed to be administered as a semi-structured interview, that gathers information about
seven areas of a client’s life: medical, employment/support, drug and alcohol use, legal, family history, family/social relationships and psychiatric
problems.
Prisons and drugs in Europe: the problem and responses
prison entry, in cases where it is required, a radiographic
examination is performed. Testing for HIV and viral hepatitis
B and C is done on a voluntary basis in all prisons and
always includes pre- and post-test counselling. It is
performed when an individual arrives in prison, one year
after previous testing or, more frequently, where medical
necessity demands. In Lithuania, since 2002, prisoners are
required by law to comply with procedures for preventing
dangerous and highly contagious infectious diseases.
In Hungarian prisons, voluntary testing for hepatitis B and C
and HIV is conducted periodically — not on prison entry —
as part of an extensive screening campaign taking place in
prisons since 2007. In Germany, rules on testing vary
between Länder, and no central dataset is available.
In most countries, a confidential health record is created
during the prison entry examination, which accompanies the
prisoner throughout the time in prison. Electronic information
systems and centralised databases are increasingly being
used to maintain a centralised overview of prisoners’ health.
Assessment of drug problems
In a majority of countries, new inmates are routinely
assessed for drug use and drug-related problems. Sixteen
countries report procedures other than urine testing to detect
illicit substances. The common approach is a clinical
assessment carried out by a medical doctor, psychiatrist or
psychologist in order to ascertain a diagnosis of drug
dependence and mental health problems, but in some
countries standardised tests, questionnaires and interviews
are used for this purpose. In Sweden, all prisoners are
classified by prison personnel with regard to level of
addiction, with a follow-up Addiction Severity Index (12)
interview when needed. In Scottish prisons, following a core
screening, inmates with drug problems are referred for
specialist substance misuse assessment. In England, CARATs
teams (Counselling, Assessment, Referral, Advice and
Throughcare services) carry out a brief substance use
assessment and, if needed, triage. In Spain, Italy and the
Netherlands, social workers and psychologists carry out a
multidisciplinary assessment, evaluate psychological, social
and legal areas and draw up an individual care plan.
The medical consultation upon prison entry is also used as a
first opportunity to inform prisoners about treatment and
prevention, raise risk awareness, distribute prevention
19
 EMCDDA 2012 Selected issue
materials, including hygiene kits and condoms, and make
referrals to specialised drug treatment and care.
Assessment of suicide risk
The importance of early identification of drug-using
prisoners at risk of suicide and referring them to adequate
treatment was shown in England, where the implementation
of an integrated treatment system in all prisons led to a
dramatic reduction in suicides among the population of
women prisoners, from a total of 36 in the preceding three
full years (2002–04) to 15 in the three years following the
start of the programme (2005–08) (Marteau et al., 2010).
Treatment of drug dependence
Treatment for drug dependence is aimed at both improving
the health of detainees and reducing the often high levels of
illicit drug use in prisons. Treatment options for drug users in
European prisons cover a range of modalities, which, in the
absence of a standard nomenclature, are broadly
categorised into three types:
1. ‘low-intensity drug treatment’, which covers counselling
interventions as well as short-term treatment conducted in
an outpatient regime within the prison setting;
2. ‘medium- or high-intensity drug-free treatment’, defined as
including inpatient wards for the delivery of drug
treatment in a residential setting, e.g. therapeutic
communities in prison;
3. ‘medium- or long-term opioid substitution treatment’,
covering methadone or buprenorphine substitution
programmes.
The following sections summarise the available information
and expert opinion about the provision of detoxification and
drug treatment services in European prisons.
Detoxification
In many countries, detoxification is still the ‘default’ treatment
for the majority of opioid users entering prison.
Detoxification policies vary between countries and can also
differ between prisons in the same country. Withdrawal
symptoms are usually evaluated by a doctor and
pharmacologically supported. Some prisons are equipped
with specific detoxification inpatient facilities for cases
where hospitalisation is necessary. In countries with smaller
prison systems, such as Luxembourg, detoxification may be
provided in collaboration with a psychiatric hospital.
Detoxification regimes vary in length and form, depending
on the individual’s clinical condition. Medically assisted
detoxification is available in all prisons in Ireland, and a
20
specialist ward with capacity for nine prisoners is operating
in the country’s largest institution, Mountjoy Prison. Here, a
typical programme includes psychosocial counselling and
lasts six weeks, which allows 70 prisoners per year to
benefit from it. In contrast, detoxification in Turkish prisons
mainly involves the provision of information on drug
addiction, increasing inmates’ skills in managing withdrawal
symptoms and craving, and training in relaxation methods.
Low-intensity treatment including counselling (outpatient)
Some form of low-intensity drug treatment was reported to
be available in prison systems in all countries except Cyprus.
The measures reported by national focal points included
psychological counselling, crisis intervention, needs
assessment and care planning, motivational programmes or
drug treatment of short duration aiming at drug use
reduction, relapse prevention or harm reduction. Among the
counselling and treatment approaches mentioned were
motivational interviewing and cognitive–behavioural and
socio-educational interventions (e.g. social skills training).
Educational and information programmes were delivered in
group sessions, whereas treatments were administered
usually in individual consultations.
The range of interventions reported was broad. In Slovakia,
for example, programmes focus on psycho-education, sports
activities and spiritual services; the Swedish Prison and
Probation Service uses mainly cognitive–behavioural
treatment programmes to address drug-using prisoners’
behavioural problems and reduce re-offending; and, in
Bulgaria, the focus of a short-term programme delivered to
prisoners in daily sessions over 20 days is the reduction of
drug-related harm.
Reports suggest that interventions aimed at spreading
general information on drug prevention and risks are
common in European prisons. These are frequently delivered
to prisoners in group settings. In 2010, nearly one-quarter of
all prisoners in the Czech Republic received at least one
intervention from drug prevention and counselling centres,
while in the same year in Latvia, 4 000 counselling sessions
and 1 700 individual consultations took place. Data from
Lithuania document that 80 % of prisoners were reached in
2010 with information about drug prevention, treatment and
rehabilitation.
Intensive and individualised counselling approaches are
more targeted, and reach a smaller number of prisoners. In
Slovenia, for example, 186 prisoners were involved in
medium-threshold treatment programmes during 2010, while
in Denmark 455 prisoners were reached by such
programmes. Furthermore, the Irish Prison Service reported
that addiction counselling services provided by 23

counsellors delivered approximately 1 500 prisoner contacts
per month, and in Luxembourg, services provided to a total
national prisoner population of 680 (on a given day)
included 45 health prevention groups, 274 individual
prevention interviews and 1 238 therapeutic counselling
sessions. In Greece, drug treatment services for prisoners
are provided by the non-governmental organisations
KETHEA and ‘18 ANO’. In 2010, more than 1 800 drug-
related counselling sessions were delivered in 19 of the 32
Greek prisons.
As most countries do not possess reliable data on the
prevalence of drug use and related treatment and
counselling needs among prisoners, the Reitox national focal
points were asked to assess current levels of treatment
provision and give information on types of providers and
models of service provision. Respondents were instructed to
judge the treatment offer against the needs of drug users
actively seeking treatment and to rank treatment providers
according to the numbers of prisoners they reach.
Capacity for low-intensity treatment was considered as
fully matching prisoners’ demand in nine countries, where
nearly all prisoners in need would obtain it. In 10 other
countries, provision was judged sufficiently extensive to
enable a majority of prisoners in need to obtain such
treatment. A lack of capacity was identified in Estonia,
Greece, Latvia, Hungary and Romania. In prisons in
Cyprus, low-intensity drug treatment programmes were not
available in 2010 (13).
National experts reported that health services run by the
prison system were the main providers of low-intensity
treatment services in 19 countries (14). External providers
were judged to make an important contribution in eight of
the 25 countries that answered the question: community-
based public health services, non-governmental
organisations that provide services through ‘in-reach’ or
mixed teams of prison personnel and externally contracted
staff were identified as main providers in Greece, Italy, the
Netherlands, Slovenia and the United Kingdom, and were
ranked on equal footing with prison health services as the
main providers in Denmark, Malta and Croatia. In France,
prison health services work under the authority of the public
health system in partnership with a hospital.
Medium- or high-intensity drug-free treatment (inpatient)
Abstinence-based residential drug treatment programmes
have a long tradition in prisons. Such programmes operate
(13) Five countries (Belgium, Spain, France, Sweden, Turkey) provided no information.
(14) No information was available from Belgium, Spain, Cyprus, Sweden, Norway and Turkey.
Prisons and drugs in Europe: the problem and responses
in a similar manner to residential programmes in the
community, providing group and individual treatments, and
professional staff may be supported by treated prisoners.
Various therapeutic models may be offered, including
cognitive, behavioural and 12-step programmes. The
UNODC Treatnet project describes the different types of
residential drug-free treatment approaches available in
prisons (UNODC, 2008a). These include cognitive–
behavioural treatment, in which structured psychological
interventions help the prisoner to develop the skills
necessary to stay drug free. Strategies include relapse
prevention such as coping strategies, identification of
high-risk situations and triggers to drug use, and identifying
dysfunctional thinking patterns, managing emotions and
problem solving.
Also used in prisons is the 12-step residential approach,
based on the Alcoholics Anonymous model, which assumes
a biological or psychological vulnerability to dependency.
The treatment goal is abstinence, and prisoners usually work
their way through the first five steps of the 12-step
programme. Programme graduates will be expected to
attend self-help groups in prison and in the community on
release.
Therapeutic communities are a special form of long-term,
participative, group-based residential treatment of drug
addiction, where milieu therapy principles are applied,
meaning that clients are encouraged to take responsibility
for themselves and for others.
There is a lack of research and evaluation of prison-based
treatment programmes and too little is known about their
effectiveness. However, two randomised trials conducted in
prisons were included in a review of the effectiveness of
therapeutic communities versus other treatments for
substance dependents (Smith et al., 2006). While the
authors found little evidence that therapeutic communities
offer significant benefits in comparison with other residential
treatment provided in community settings, inmates of
prison-based therapeutic communities were less likely to
return to prison within the first 12 months after, compared
with prison inmates receiving no treatment or assigned to
alternative services. Thus, prison therapeutic communities
may be better than prison on its own, but a number of
methodological limitations are mentioned by the authors,
preventing them from drawing firm conclusions. The fact that
both trials were conducted in US prisons may limit the
transferability of the results to Europe.
21
 EMCDDA 2012 Selected issue

Figure 3: Estimated availability of residential drug-free treatment Prison health services are the main provider of drug-free
in European prisons inpatient treatment in 16 countries, with external providers
or mixed teams playing an equal role in Denmark and
Malta, and a main role in Italy, Slovenia, the Netherlands
Full and the United Kingdom.
Extensive
Limited
Rare Opioid substitution treatment
Available at
unknown level
Not available Substitution treatment is the main approach in the treatment
No data
of opioid dependence in the European Union and is
implemented in all Member States, Croatia, Turkey and
Norway. With around 710 000 opioid substitution
treatments reported in 2010, it covers at least one in two of
the estimated population of problem opioid users (EMCDDA,
2012). Most European countries have introduced substitution
treatment among the range of options for opioid-dependent
prisoners, and the ‘treatment gap’ between community and
prisons may now be closing, at least in some countries
(Hedrich and Farrell, 2012). However, there has been a
considerable delay in introducing opioid substitution
NB: Availability is defined by the estimated proportion of drug users in treatment in prisons, which has generally occurred about
need of treatment who can receive it: nearly all (full); the majority, eight to nine years after the treatment option was
but not nearly all (extensive); more than a few, but not the majority
implemented in the community (see Figure 4).
(limited); only a few (rare); not available.
Sources: Reitox national focal points.
A systematic review of the effectiveness of opioid
maintenance treatment in prison (Hedrich et al., 2012)
analysed data from 21 studies, including six experimental
Residential drug-free treatment is provided through
studies. The authors concluded that the benefits of the
therapeutic communities or special inpatient wards in 21 of
treatment in prison are similar to benefits in community
the 25 countries that provided information (Figure 3). Cyprus
settings; namely, it presents an opportunity to recruit
established a drug-free treatment inpatient programme in
problem opioid users into treatment, to reduce illicit opioid
2011.

Drug-free inpatient treatment or therapeutic communities in

Figure 4: Cumulative number of European countries that had
prison was considered to be available to all or almost all of
officially launched opioid substitution treatment as a
those who need it in four (Denmark, Lithuania, Luxembourg, recognised method of treatment in community and
Croatia) of the 21 countries that were able to provide prison settings
information, and to a majority of prisoners in a further nine of
these countries (Figure 3). This type of treatment was seen as
available to more than a few but not a majority of prisoners 30
Community
in need in six countries, namely the Czech Republic, Estonia,
25
Greece, Malta, Finland and Norway and restricted to just a
few prisoners in Ireland, Latvia and Romania. 20

Four countries did not provide a rating of the provision of 15 Prison

drug-free inpatient treatment in prisons, but gave some
additional information in their national report, which allows 10

the conclusion that such services exist in three of them.

5
While in Spain these take the form of residential ‘treatment
and educational units’ set up in 12 prisons, much of the
0
Swedish inpatient service provision seems to follow the
1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
12-step Minnesota model. And with Belgium now also
planning to start up a therapeutic community, the only
country for which no information is available is Turkey. Sources: Reitox national focal points.

22
 Prisons and drugs in Europe: the problem and responses

use and risk behaviours in prison and potentially minimise
overdose risks on release. Positive outcomes depended on
the quality of treatment. The review highlights the
importance of establishing a liaison between prison and
community-based programmes in order to achieve
continuity of treatment and longer-term benefits. The data
also show that disruptions in the continuity of treatment,
especially owing to short periods of detention, are
associated with very significant increases in hepatitis C
incidence.
In 2012, Greece, Cyprus, Lithuania and Slovakia are the
only countries where prison doctors are not allowed to
prescribe long-term substitution treatment (15). In Hungary,
although the treatment has been officially allowed in prisons
since in 2001, it was only implemented in a few isolated
cases in the years 2005–06. In Turkey, an option to provide
substitution treatment has been available in prisons since
2010, but the availability of substitution maintenance
treatment as compared with reduction programmes is not
clear. In 2011, Latvia permitted opioid substitution treatment
to be used in the long-term care of prisoners, extending the
current model of reduction treatment to a maintenance
approach. In all other countries, drug users who are
receiving substitution treatment in the community can
continue upon entry to prison. In addition, this treatment can
also be initiated during the period of detention in most of the
countries where continuation is possible, with the exception
of the Czech Republic, Latvia, Poland and the United
Kingdom (Northern Ireland).
In order to describe the level of implementation of opioid
substitution treatment, in the absence of reliable data on
the number of opioid-dependent prisoners, two
complementary approaches have been followed. First, the
proportion of prisoners receiving opioid substitution
treatment was calculated (16). In addition, because this
method does not differentiate between countries with high
or low levels of problem opioid use, national focal points
were asked to provide an expert rating on the level of
provision in relation to the number of prisoners in need of
treatment. The results of the two methods are in broad
agreement (Table 2).
It is estimated that opioid substitution treatment is received
by more than 10 % of all prisoners in seven EU Member
States, and by between 3 % and 10 % in another nine
countries. Compared with 2008 (17), provision has increased
in most countries.

Table 2: Provision of substitution treatment in prison: comparison of expert ratings and the
percentage of prisoners reported to be receiving substitution treatment
Percentage of prisoners receiving opioid substitution treatment in 2010

Expert rating on Zero Less than 3 % 3 % or more, but 10 % or more

provision in 2010 less than 10 %

Full Estonia Denmark Ireland, Spain, Luxembourg,

Austria, Slovenia,
United Kingdom

Extensive Poland France, Netherlands,

Portugal, Norway

Limited Czech Republic, Romania Italy, Croatia Malta

Rare Finland

Treatment not available Greece, Cyprus, Lithuania,

Slovakia, Turkey

Expert rating not available Latvia, Hungary Bulgaria, Sweden Belgium, Germany

NB: Availability is defined by the estimated proportion of drug users in need of treatment who can receive it: nearly all (full); the majority, but not nearly
all (extensive); more than a few, but not the majority (limited); only a few (rare); not available.
Sources: Reitox national focal points.

(15)  See Table HSR-9 and Figure HSR-4 in the 2012 Statistical bulletin.
(16) Two different methodologies were used and are described in Figure HSR-4 in the 2012 Statistical bulletin. See Table HSR-9 for information on the numbers
of opioid substitution treatments reported.
(17)  For 2008 data, see Figure HSR-4 in the 2010 Statistical bulletin.

23
 EMCDDA 2012 Selected issue

Prevention of drug-related infectious Figure 5: National priorities in the prevention of infectious

diseases in prison settings diseases among drug users in prison settings

Prisoners are at great risk of contracting infectious diseases:

they are exposed to an often overcrowded environment with Other
higher levels of disease prevalence and fewer options to Individual risk
protect themselves from infections than they would have assessment and
one-to-one infectious
outside (Laticevschi, 2007). By providing inadequate disease counselling
healthcare for inmates with communicable diseases, prisons Dissemination of
information on
may place at risk both other inmates and the public (APHA infectious diseases
Task Force on Correctional Health, 2003). Low-intensity drug
treatment (1)
A solid evidence base exists for a number of cost-effective
Medium or long-term
public health interventions to reduce and control infections subsitution treatment
among drug users (ECDC and EMCDDA, 2011). These
Initiation of opioid
include testing, vaccination and treatment of infections, as substitution treatment
well as interventions aiming at the reduction of drug use and
Medium or
injecting-related risk behaviour, ranging from health high-intensity drug-free
treatment (2)
promotion and drug dependence treatment to needle and
Voluntary infectious
syringe programmes. disease counselling
and testing on
prison entry
The survey among national focal points sought to identify
Hepatitis vaccination
national priorities in the prevention of infectious diseases programme
among drug users in prison settings (18). Twenty-five countries 0 2 4 6 8 10 12 14
answered the question, and the most commonly identified Number of countries
priority measures were hepatitis vaccination programmes
and voluntary infectious disease counselling and testing on (1) Including counselling.
prison entry (Figure 5). Furthermore, drug treatment was (2) Prison treatment centres, specialised prison treatment wards.
identified as a priority for preventing infectious diseases in Sources: Reitox national focal points.

prison settings: 10 countries prioritised drug-free treatment in

specialised prison treatment wards or prison therapeutic
communities, eight of which also identified the option of
initiating opioid substitution treatment in prisons or of
placing prisoners in medium- or long-term opioid substitution
programmes as a strategic priority. One or both opioid
substitution measures were identified as a priority in 15 of
the 25 countries. Counselling, individual risk assessments
and the dissemination of information materials about
infectious disease prevention were less often identified as
priority interventions.
Survey respondents were asked to judge the extent to which
the availability of selected prison interventions matched the
demand in their country. The results indicate that testing for
hepatitis C on prison entry was available to a majority or
nearly all of those who need it in 17 countries.
Hepatitis B vaccination programmes in prison exist in 16 of
the 26 countries that were able to provide information, and
drug users are their main target group. Some countries
report specific accelerated schedules, others the general use
of the combined hepatitis A and B vaccine. Data on the
uptake of such vaccinations are, however, extremely scarce.
In Scotland, hepatitis B vaccination has been offered to all
prisoners within 24 hours of admission since 1999, and,
since 2000, all prisoners diagnosed with HCV infection
have been offered the hepatitis A vaccine. Since 2009, both
vaccines are routinely offered to all drug-using prisoners on
admission.
Survey respondents perceived the availability of individual
counselling on drug-related risk behaviour as either rare or
limited in 13 countries, while such counselling was seen as
being available to a majority or nearly all of those who
need it in 11 countries. Safer drug use training was offered
in prisons in 12 countries, but availability was mainly
perceived as limited or rare (10 countries). Such training was
not available in seven countries, and 11 countries provided
no information on the availability of this measure.

(18)  It was possible to add up to two additional measures under ‘other’. However, only one country made use of this option.

24
 Prisons and drugs in Europe: the problem and responses

Needle and syringe programmes provision of treatment represents, however, a considerable

challenge to national prison systems, not only because of its
Needle and syringe programmes exist in prisons in five EU high costs, but also because it requires a multidisciplinary
Member States (Germany, Spain, Luxembourg, Portugal, approach with collaboration between experts in infectious
Romania), although varying levels of provision are reported. diseases and drug dependence treatment.
While the capacity for syringe provision in the programme
operating in the main prison in Luxembourg is considered to Hepatitis C testing is not always offered to or requested by
be sufficient to meet injecting prisoners’ needs, and the prisoners, and as the infection is often asymptomatic, many
majority of prisoners in Spain (19) who need syringes can do not know if they are infected. In some cases, the high
obtain them from programmes running in 41 prisons, access costs of subsequent treatment may determine whether the
to the programme in Romania is described as low, with just prison health system offers the test.
83 prisoners taking part during 2011 in the programmes
A growing body of evidence from European prisons shows
established in 10 prisons. In Portugal, where a legal basis
that hepatitis C treatment is feasible and effective in these
for prison needle and syringe programmes has existed since
settings. Currently, the state-of-art treatment for this infection
2007, a study cited in the Reitox national report shows that
is the use of pegylated interferon and ribavirin, but new
the two programmes established in 2008 were not accepted
drugs are under development. While a number of logistical
by the inmates, who feared discrimination (20). In Germany,
and medical challenges (e.g. addressing the side-effects of
only one site from a wider model project on prison syringe
interferon; treatment of co-infections and psychiatric
exchange, conducted until the end of 1998, remains in
disorders) exist, a prison stay can create an opportunity for
existence. In the women’s prison Berlin Lichtenberg,
treatment. Tan et al. (2008) investigated the cost-
prisoners can anonymously obtain sterile syringes at vending
effectiveness of hepatitis C treatment with pegylated
machines.
interferon and ribavirin in the US prison population, and
Although the introduction of needle and syringe concluded that the treatment results in both improved quality
programmes in prisons is recommended by international of life and cost savings for almost all segments of the inmate
organisations (UNODC, 2012), and expert groups in several population.
European countries have considered the measure (e.g.
The available data on the provision of hepatitis C treatment
France, Hungary, Austria, United Kingdom, Norway), they
in prison, although scarce, seem to indicate that only a
face strong opposition, as they are often perceived as
small proportion of those who have contracted the infection
contradictory to the goal of a drug-free prison. Several
are treated. In the Netherlands, in order to avoid
countries provide disinfectants as an alternative. In
interruption of treatment on release, only prisoners
Denmark, France, Lithuania, Austria, Finland, the United
sentenced for more than 6 months are given the option of
Kingdom and Norway, chlorine rinse fluid or other
starting treatment. Short-term prisoners are referred to
disinfectants are made available. While laboratory studies
treatment in the community. A study among prison doctors
have shown efficacy of using bleach to eliminate HIV
in Germany found that 6 % of prisoners infected with HCV
(Abdala et al., 2001), it has been doubted whether this
received treatment. In Hungary, 48 prisoners started
measure is sufficiently safe under ‘real-life’ conditions in
antiviral hepatitis C treatment in 2010, and in the Czech
prison. In three countries (Belgium, Hungary, Netherlands),
Republic 56 cases were registered. In France, a recent
recent studies showing a low level of injecting drug use
study reported that nearly half of HCV-positive inmates had
among the prisoner population are cited as the reason that
received a treatment (Semaille et al., 2011), while an earlier
needle and syringe programmes are not prioritised.
retrospective mail survey among French prisoners and a
retrospective prison study reported hepatitis C treatment
Treatment of hepatitis C in prison uptake in the range of 14 % (Remy, 2006) and 23 % (Allen
et al., 2003) of HCV-positive prisoners. A prospective study
As injecting drug users constitute a sizeable proportion of
of 268 HCV-positive prisoners in Luxembourg showed a
the population infected with HCV, and many of them can be
hepatitis C treatment uptake of 32 % among this population
reached in prisons, this setting provides an opportunity for
(Strock et al., 2009).
treatment to reduce the national burden of hepatitis C and
eliminate prison-to-community spread of the disease. The

(19)  Including 10 prisons in Catalonia.

(20) The programme was developed in the framework of a pilot project, and was implemented in the prisons of Lisbon and Paços de Ferreira between July
2008 and March 2009.

25
 EMCDDA 2012 Selected issue

Release preparation and throughcare facility aimed at those who have completed drug treatment
and are entitled to less restrictive conditions, including visits
Most social care and rehabilitation strategies and
to the outside in an open prison regime, thereby allowing
procedures for those leaving prison are directed at the
the prisoners to organise their future housing and
general prisoner population. However, some pre-release
employment before release.
measures are particularly important for those who use or
have used drugs. A number of interventions targeting opioid users have been
recommended to reduce the risk of a fatal overdose in the
Of special importance for drug users during the phase
period shortly following prison release (22). They include
immediately preceding prison release — but ideally a
pre-release counselling on overdose risk and training in first
process throughout the whole sentence — is cooperation
aid and overdose management; optimising referral to
between services inside the prison with health and social
achieve continuity of drug treatment between prison and
services outside, to ensure a seamless transition into
community; and the distribution of naloxone among opioid
community treatment. The term ‘throughcare’ refers to
users leaving prison. Reliable data about the availability of
arrangements for managing the continuity of care before,
pre-release measures are scarce. However, provision of
during and immediately after custody (21). Throughcare and
naloxone on prison release is available across the England,
referral to external service providers is a general duty of
Scotland and Wales prison estates, but is not reported from
prison or probation services, and can be crucial in
other countries. Examples of good practice for community-
preventing relapse (Prison Drug Treatment Strategy Review
based organisations have been collected in the ‘Through the
Group, 2010). In countries where prison and community
gate’ scheme in Wales and include ‘in-reach’, prison gate
health services operate ‘under the same roof’, throughcare
pick-up, assertive outreach, local networking and enhanced
between the two settings is easier to achieve, as integrated
engagement with support services.
programmes operating inside prison can establish links into
the community before the prisoner leaves the institution. In Although the European Prison Rules specify that prisoners
some prison systems, pre-release units have been set up to should be offered a medical examination as close as
facilitate such referrals and to allow a smoother transition. possible to the time of release, a routine ‘exit’ health
One example is the central intake units in Flemish prisons, examination does not seem to be common in Europe: only
funded by the Ministry of Justice and run by external drug reports from Croatia and Slovakia mentioned this as a
workers whose task is healthcare provision. Similarly, the statutory service in their prison systems.
‘exit unit’ in the Portuguese prison system is a residential

(21)  A throughcare toolkit was produced under the EU-funded research project ‘Throughcare for prisoners with problematic drug use’ and is available online.
(22)  See the section ‘Mortality after prison release’.

26
Conclusions
The current EU drugs action plan calls on Member States to
increase the use of effective alternatives to incarceration of
drug-using offenders. Despite evidence of an increased
interest in providing ‘alternatives to prison’, many people
with drug problems continue to pass through Europe’s prison
systems every year. Drawing on the available information,
this Selected issue has presented an up-to-date overview of
both the drug situation and health and social responses to
drug-related problems in European prisons.
All evidence points to the fact that, when compared with
the general population, prisoners as a group are
particularly disadvantaged and marginalised. Most
prisoners have limited education and low socioeconomic
status, and poverty, violence and crime are common
experiences in prisoners’ lives. Incarcerated non-nationals,
who account for more than 20 % of all prisoners in 13 EU
Member States (Table 3.2 in Aebi and Del Grande, 2012),
are among the most vulnerable prisoners. Similarly, women
prisoners, although accounting for only a minority of prison
inmates, are a group with complex health and social
needs. Surveys on prison health also document elevated
levels of physical and mental health problems among
prisoners, often coupled with chronic and entrenched drug
use problems.
Drug-using prisoners: an
opportunity for intervention
Studies confirm that both drug use and drug use-related
health problems are far more common among prisoners than
in the general population. Lifetime prevalence of substance
use, including illicit drug use, is reported to be very high
among prisoners, with levels of up to 80 % for tobacco and
cannabis use and up to 50 % for cocaine, heroin and
amphetamines consumption. Although many prisoners stop
or reduce their drug use when they enter prison, some
continue to use drugs, sometimes switching to different
substances or starting an additional drug while incarcerated.
There is also evidence that some prisoners, who have never
used drugs before, have their debut with illicit drugs while in
prison.
In Europe, drug users represent a large proportion of the
prison populations and, for some, periods of incarceration
may offer an opportunity to reduce their drug use and
engage with services. In this respect, imprisonment may be
viewed as a chance to make contact with and provide
treatment for a particular group of ‘hard to reach’ problem
drug users, leading to their better health and also reducing
risks to the community on their release. The current EU drugs
action plan prioritises the further development and
improvement of drug-related assistance for detainees,
including better access to drug-related prevention, treatment,
harm reduction and rehabilitation services, of a standard
that is comparable to the services provided in the
community. Opportunities in this area have been increasing,
as many countries have scaled up their provision of
interventions within prisons, in particular offering more
substitution treatment slots for those who are opioid-
dependent. However, in spite of progress in many European
countries, the extent and quality of prison health service
delivery still varies widely between countries, and rarely do
prison health services offer an equivalent and comparable
standard of care to that provided to the wider community.
A number of recent European and international studies have
identified a very high risk of drug overdose mortality among
newly released prisoners owing to relapse into heroin use
alongside reduced tolerance. The time around release is a
particularly important period for preventive interventions,
such as pre-release counselling, as well as for ensuring
continuity of care on release in order to keep vulnerable
individuals in contact with services and reduce drug-related
deaths.
Prisoners’ health: complex service needs
Drug users among prisoner populations often suffer from
multiple mental health and somatic co-morbidities, and
require specialised services to treat both their drug use and
health problems. Mental health problems are very common
among prisoners, and may be associated with the high
levels of self-harm that are documented in prison, where
suicide is the leading cause of death. A particular concern
for this group is the transmission of infectious diseases such
27
 EMCDDA 2012 Selected issue
as hepatitis C, tuberculosis and HIV/AIDS in prisons.
Drug-using prisoners often share needles and other
paraphernalia, increasing their exposure to infectious
diseases. Poor living conditions, such as overcrowding and
poor hygiene, aggravate the risk of infections and decrease
prison’s safety. As prisoners move into and out of the
general community, failure to maintain healthy living
conditions in prison will impact negatively on the health of
the community in general. More positively, imprisonment
may provide an opportunity to intervene and provide
treatment of infectious diseases, including hepatitis C,
leading to improved prisoner health and also reducing risks
to the community on their release.
Data limitations
The information available on drug use and responses in
prison settings has a number of methodological limitations,
which relate to both the nature of the subject (drug use and
prison) and the lack of standardisation in data collection
tools within and between countries. Data collection and
research within prison settings are particularly affected by
biases associated with self-selection, self-reporting and
clustering. There are threats to validity linked to the
sensitiveness of the topic (illicit drug use) and of the setting
of the study (prison). In the prison setting, ethical aspects
are especially important when collecting data, in particular
with regard to confidentiality, anonymity and data
protection issues. The use of relevant anonymised data
from individual health records would be another option,
but clear policies regarding confidentiality and data
protection are needed when such data are collated at a
central level.
This report documents the progress that has been achieved
in drugs service provision in prisons with regard to the use
of evidence-based approaches. However, a number of
serious shortcomings remain. At the European level there, is
a lack of harmonisation of data collection: methodological
differences can be found with regard to types of study,
sampling methods, target populations and variables studied.
These differences make it very difficult to draw comparisons
between countries, and limit the possibilities for presenting a
complete and comprehensive European picture of problems
related to drug use in prison as well as an objective
assessment of the need for and provision of drug-related
health responses in prisons.
28
Data monitoring on drugs and prison in
Europe: a need for common standards
This review has demonstrated that prison health service
delivery varies widely between countries, and that in many
cases the evaluation and monitoring of drug-related health
services are rare and do not follow the same standards.
Under the last EU drugs action plan, which is coming to an
end in 2012, Member States are called to endorse
indicators to monitor drug use, drug-related health problems
and drug services in prison on the basis of a methodological
framework. As a complement to the healthcare-related
recommendations of the European Prison Rules, an EU
monitoring framework of drug-related prison health would
address national drug-related prison health policies; data
collection and monitoring infrastructures as well as quality
standards and guidelines for drug-related services and
interventions in prisons. A corresponding set of indicators on
service needs (drug use, risk behaviours, health
consequences) and service provision would facilitate the
collection of objective, reliable and comparable data on
drug-related prison health in Europe.
Closing the gap between prison and
community: equivalence of care
There is wide recognition among EU policymakers of the need
to harmonise practice and quality of health and social care
services between community and prisons, and to respond
better to the more severe health situation of the prisoner
population. Progress has been made in some European
countries, although the gap between prison and community in
terms of levels and quality of health services available to
prisoners still remains wide. Prison healthcare has, in the past
decade, increasingly been recognised as part of public
healthcare, and, consequently, several countries have
transferred the responsibility for the healthcare of prisoners
from justice ministries or the prison administration to health
ministries. Others have drawn up specific drug and health
strategies or regulations for the prison setting. A strong
argument exists that any successful approach to improving
prison health in the future must recognise the importance of
including harm reduction and drug treatment services
alongside, and integrated with, generic somatic and mental
healthcare responses, a functioning throughcare mechanism
in the community and substantial efforts to improve the
reintegration of former prisoners.
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31
European Monitoring Centre for Drugs and Drug Addiction

Prisons and drugs in Europe: the problem and responses

Luxembourg: Publications Office of the European Union

2012 — 31 pp. — 21 x 29.7 cm

ISBN 978-92-9168-561-5
doi: 10.2810/73390
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 TD-SI-12-002-EN-C
About the EMCDDA
The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) is
one of the European Union’s decentralised agencies. Established in 1993 and
based in Lisbon, it is the central source of comprehensive information on drugs
and drug addiction in Europe.

The EMCDDA collects, analyses and disseminates factual, objective, reliable

and comparable information on drugs and drug addiction. In doing so, it
provides its audiences with an evidence-based picture of the drug
phenomenon at European level.

The Centre’s publications are a prime source of information for a wide range
of audiences including policymakers and their advisors; professionals and
researchers working in the field of drugs; and, more broadly, the media and
general public.

ISBN 978-92-9168-561-5